Thoracic Imaging - Basic Approach t Chest A h to Ch t Radiographic Anatomy

Department of Radiology, p gy, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca

Learning Objectives

Be able to evaluate technical factors required for an adequate interpretation of a chest x-ray with respect to Penetration Inspiration Rotation Magnification Angulation

Learning Objectives Continued

Be able to identify the following structures on a PA chest x-ray: Lungs & Airways Trachea Hila Right and left mainstem bronchi Right Lobe: upper, middle, lower lobes Left Lobe: upper & lower lobes Mediastinum Heart borders Transverse thoracic aorta Pulmonary trunk Atrial appendage p y Aorto-pulmonary window

Learning Objectives Continued

Be able to identify the following structures on a PA chest x-ray: Diaphragm Costodiaphragmatic recesses Bones Clavicles Spine Scapula Humerus Sternum Ribs

Learning Objectives Contd

Be able to identify the following structures on a PA chest x-ray: Sternum Right ventricle Vertebral bodies

Chest Radiography

Very Inexpensive Most M t common requested exam t d Easily obtained 2D representation of a 3D t ti f anatomic structure Usually first line imaging of the chest Excellent for emergency, line placement, post surgical imaging and query abnormality

Arrow indicates malpositioned tube. Normally, the ET tube should be at least over 3cm above level of carina.

PLAIN RADIOGRAPHY

Involve passing x-rays through patients body to expose a photographic plate

X-ray Unit

INTRODUCTION TO THE CHEST X-RAY XHow the radiograph is taken - Technique

Anteroposterior (AP) View

PA

AP

Basic Information

metal fat bo e bone

5 Radiographic Densities you should be aware of bone fat

air Water, soft tissue

metal

Water, soft tissue ft ti

air

Chest xray

CT

Introduction to the Chest X-Ray How the radiograph is taken - Technique

Posteroanterior (PA) View Standard view, taken on full inspiration Patient stands with anterior chest wall against the film cassette X-ray beam enters from behind

Anteroposterior (AP) View Magnifies the cardiac and mediastinal shadows (approx. 20%)

Chest X-ray Technique

PA

AP

TECHNICAL FACTORS QAULITY

Rotation
Spinous processes should project midway between medial heads of clavicles

Inspiration
Dome of right hemidiaphragm projects over the anterior 6th interspace and posterior right 10th interspace g p

Exposure
The lower thoracic disc spaces should be seen through the cardiac silhouette

Determining Adequacy of the Film

Penetration: Disk spaces of the thoracic spine can be seen behind the heart, but t bony d t il of h t b t not b details f the spine

Determining Adequacy of the Film

Inspiration: Diaphragm is below ribs 8-10; 9-10 ribs can be seen posteriorly t i l

9 10

Determining Adequacy of the Film

Rotation: Clavicles are equidistant from the spinous processes

Determining Adequacy of the Film

Magnification: The heart appears larger on an AP film than on a PA film due to the heart being further d t th h t b i f th from the film and casting a larger shadow Standard chest x-rays are PA Portable chest x-rays are x rays most often AP

PA film shown here

Determining Adequacy of the Film

Angulation Clavicle is over the 3rd rib If the beam is angled towards the head due to patient posture, the clavicle would appear higher and structures, eg. heart, eg heart would appear distorted

BASIC ANATOMY

Trachea Transverse thoracic aortic arch Left hilum Left atrial appendage Left ventricle

SVC / Azygos confluence Right hilum

Right atrium

Right hemidiaphragm

Costophrenic angle

Sternum

Thoracic Vertebral bodies

RT Ventricle abutting retrosternal space

Left Atrium

Posterior margin of LT ventricle

Normal Lateral Chest

MAJOR AIR WAYS

TRANSVERSE PORTION OF THE THORACIC AORTA

Heart Chambers

Coronal mediastinal structures: Gross vs CXR

3 1 3

1. Right atrium g 2. Right ventricle 3. Left ventricle

Coronal mediastinal structures: CXR vs CT

1 2 3

2 4 5 6 7 8 7 5

3 4

6 8

1. 2. 3. 3 4.

Trachea Superior Vena Cava Aortic Arch A ti A h Pulmonary Trunk

5. 6. 7. 7 8.

Right atrium Left ventricle Right hemidiaphragm Ri ht h idi h Costophrenic angle

Coronal mediastinal structures: Gross vs CXR

1 3 2

3 2 4 5 6 5 6 4

1. Trachea 2. Superior Vena Cava 2 3. Aortic Arch

1. Pulmonary Trunk 2. Right Atrium 2 3. Left Ventricle

Coronal mediastinal structures: Gross vs CXR

1. Trachea 2. Superior Vena Cava 2 3. Aortic Arch

4. Aortopulmonary Window 5. Pulmonary Trunk 5

Looking at Chest Wall / Soft Tissues

Check each rib individually Check clavicles Check for the presence or absences of breasts

Check for presence of soft tissue masses

Vertebra o Ch k b d pedicles, spinous Check body, di l i process, disc space.

ANTERIOR

POSTERIOR

Chest Wall: Ribs

Posterior Ribs More apparent on PA film P Up to 10 visible on full inspiration P P

Anterior Ribs A Less visible on PA film A A

Chest Wall: Counting Ribs

Posterior Ribs -more apparent on PA film -up t 10 visible on full to i ibl f ll inspiration Anterior Ribs -less visible on PA film P

Chest Wall: Counting Ribs

Posterior Ribs -more appa e t o PA o e apparent on film -up to 10 visible on full inspiration
A

P P P

Anterior Ribs -less visible on PA film l i ibl fil

A A

Posterior Ribs
1 2 3 4 5 6 7 8 9 10

Diaphragm
Point where diaphragm meets chest wall forms a sharp acute angle angle, namely the lateral and posterior costophrenic angles (arrows). Right hemidiaphragm normally about 2cm higher than left. g p g y g

R L

Coronal mediastinal structures: Gross vs CXR

2 1 1 2

1. Right hemidiaphragm 2. Costophrenic angle 2

Pleura

Pleura extends to the: 8th rib in the midclavicular line 10th rib in the midaxillary line, and to the 12th rib posterior

Pneumothorax - Air in Pleural Space

Visceral pleura

Mediastinum
The mediastinum is the space between the spine at the back, the sternum at the front, and the front lungs at the sides Middle It is divided into the anterior, middle and posterior mediastinum Anterior Posterior

Lateral film helpful but usually will need a CT scan for further investigation

M P

Thymic mass in anterior mediastinum

Hila

Comprised of lobar bronchi, central/lobar pulmonary arteries, veins, lymph nodes

The left hilum is slightly higher than the right in normal individuals

Maybe enlarged by arteries arteries, masses or enlarged lymph nodes

HILUM

Coronal mediastinal structures: CXR vs CT

1 2

4 3

2 4

1. 2. 3. 3 4.

Trachea Aortic Arch Right hilum Left hilum

Coronal mediastinal structures: CXR vs CT

1 4 2 5 3 6 5 2 3 6 1

1. Trachea 2. Right Main Bronchus 3. Left Main Bronchus

1. Aortic Arch 2. Right Hilum 3. Left Hilum

Coronal mediastinal structures: Gross vs CXR

1 2 1

1. 2. 3. 3 4.

Trachea Aortic Arch Right hilum Ri ht hil Left hilum

Coronal mediastinal structures: Gross vs CXR

1 4

4 5

3 6

5 3

1. Trachea 2. Right Main Bronchus g 3. Left Main Bronchus

4. Aortic Arch 5. Right Hilum g 6. Left Hilum

Pulmonary P lmonar Lobar Anatom Anatomy

Axial (transverse) mediastinal structures: Gross vs CT

5 3 5 3 1 4 2 6 2 1 4 6

1. 2. 2 3. 4. 5. 5 6.

Right Major (oblique) fissure Left major (olbique) fissure Right Upper Lobe Right Lower lobe Left Upper lobe Left lower lobe

3 2 4 6

5 1

Cross Sectional CT Imaging of Lungs

3 5 1 6

4 7 3 5 2 8 6

7 2 8

1. 2. 2 3. 4. 5.

Right Major (oblique) fissure Left L ft major ( bli j (oblique) fi ) fissure Right minor (horizontal) fissure Right Upper Lobe Right Middle lobe Ri h Middl l b

6. 6 7. 8.

Right Lower l b Ri ht L lobe Left Upper lobe Left lower lobe

Coronal

Saggital

Transverse

Coronal CT Imaging of Lungs

4 7 3 5 8 2 1 6 8

3 5 1 6

1. 2. 3. 4.

Right Major (oblique) fissure Left major (oblique) fissure g (horizontal) fissure ) Right minor ( Right Upper Lobe

5. 6. 7. 8.

Right Middle lobe Right Lower lobe Left Upper lobe pp Left lower lobe

The Right Lung

The Right Lung

Major fissure

The Right Lung

Minor fissure (Horizontal Fissure)

The Right Upper Lobe

RUL

RUL

Right Middle Lobe

RML RML

Right Lower Lobe

RLL RLL

The Left Lung

Left Lower and Upper Lobes

LUL

LUL

LLL LLL

Normal Lateral Chest

Sagittal mediastinal structures: Gross vs CXR

1 3 3 2 2 4 7 5 4 5 6 7 6

1. Sternum 2. Right Pulmonary Artery 3. 3 Thoracic Aorta (Ascending Aorta) 4. Left Atrium

5. Right Ventricle 6. Inferior Vena Cava 7. 7 Vertebral Body

LOOKING AT THE LUNGS

Radiographic appearance is pp comprised of gas filled alveoli (black) and pulmonary vessels (white) Bronchi dont normally contribute radiographic density Vessels are recognized by their tapering and branching pattern

NORMAL

PULMONARY EDEMA